Coverage Requirements

SECTION SUMMARY:

35+ Body Mass Index (BMI)

Documentation of failed diet attempts

Psychological evaluation

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Even if your insurance company covers bariatric surgery in some plans, that does not mean that your specific plan covers it. The obesity surgery approval requirements in this section assume that weight loss surgery is covered by your specific policy.

Disclaimer: The information contained on this page may not include all components of your insurance company’s medical policy and/or may not be up to date. Contact your insurance company to confirm all benefits.

In order to be approved by Health Net for bariatric surgery in the United States, you must meet the following criteria:

Patient is between 18 and 65 years of age (unless the patient is over 65 years of age and is considered a low-risk candidate for surgery)

For at least 2 years or greater, the patient has clinically severe obesity (morbid obesity) defined by either of the following:

Hypercholesterolemia > 240 mg/dL that has not responded to medical therapy

Hypertriglyceridemia > 400 mg/dL that has not responded to medical therapy

Low density lipoprotein (LD) >130 that has not responded to medical therapy

High density lipoprotein (HDL) < 35 that has not responded to medical therapy

Impaired fasting glucose > 125

Pulmonary hypertension

Patients with History of Alcohol / Hard-Core Substance Abuse

Patients with a history of alcohol or hard-core substance abuse should not be considered a candidate unless there is a record of at least one year of abstinence, which must be documented by random negative urine samples/blood alcohol levels/breathalyzer testing.

If there has been a one-year abstinence, this condition must be addressed in a psychiatric consultation.

Use this BMI Calculator to check your body mass index…

Patient has made a reasonable effort to lose weight and chart notes must document that these attempts at dietary control have been ineffective in achieving a medically significant long-term weight loss.

Published peer-reviewed studies have shown that superobesity was the most important risk factor for perioperative complications, during bariatric surgery. Although patients undergoing bariatric procedures invariably have a history of failed dieting, preoperative weight loss can improve patient safety for these procedures. Aggressive medical therapies, such as very low calorie diets, are transiently effective for morbidly obese patients. The major limitation of medical obesity treatments for these patients is generally unsustainable weight loss rather than an inability to lose weight at all. Given these circumstances, preoperative weight loss can prove to be a reasonable approach to reduce adverse outcomes for superobese bariatric surgical patients but is not required prior to surgery

All patients must undergo a preliminary psychological evaluation by licensed mental health care professional (LCSW, MFCC, MSW PhD) familiar with the implications of weight reduction surgery. If pathology is identified, then an evaluation by a psychologist / psychiatrist is required and the member must receive clearance before surgery is performed

Adolescents Requirements

Patient is an adolescent between 14 and 17 years of age and all of the following criteria are met:

Patient has made a reasonable effort to lose weight and chart notes must document that these attempts at dietary control have been ineffective in achieving a medically significant long-term weight loss

Attainment or near-attainment of physiologic maturity (Tanner stage V) – in some cases, a bone age may be required to determine skeletal maturity as evidenced by fused epiphyses

Adjustable gastric banding surgery is contraindicated in patients with gastroesophageal reflux pre-operatively, those who plan to stay on nonsteroidal anti-inflammatory drugs and other mucosal irritating drugs

Psychological disorder(s) of a significant degree that a psychologist / psychiatrist thinks it would be exacerbated by or interfere with the long term management of the patient after the operation, such as:

Active substance and alcohol abuse

Significant eating disorders

Untreated schizophrenia

Uncontrolled major depression

Manic-depressive disorder

Psychotic disorders

Borderline personality disorder

Mental retardation

Psychological criteria to exclude patients from consideration for surgery:

Severe Binge Eating Disorder as measured by Questionnaire on Weight and Eating Patterns (QWEP-R) and confirmed by clinical interview

Unstable social environment (homeless, lack of access to a kitchen, lack of social support) as assessed by clinical interview

Very low self-efficacy/self-motivation/personal responsibility as evidenced by low Multidimensional Health Locus of Control (MHLC) scores and confirmed by clinical interview

Other severe behavioral problems as evidenced by scores on Million Behavioral Medicine Diagnostic (MBMD) or Optional-Minnesota Multiphasic Personality Inventory (MMPI) and confirmed by clinical interview

Revision Requirements

A Repeat / Revision Surgery will be approved if it is medically necessary to correct any of the following complications:

Roux-en-Y Gastric Bypass:

Abdominal catastrophe – the complication of peritonitis from an anastomotic or staple-line leak

Bowel obstruction or stricture of the stoma between the pouch and the intestines, stomal ulceration

A Note About Revision Surgery

Inadequate weight loss due to individual noncompliance with postoperative nutrition and exercise recommendations is not a medically necessary indication for revision surgery and would not be an indication for coverage.

Lap-Band:

Pouch dilatation (also vertical banded gastroplasty)

Stomach slippage

Band erosion

Band or tubing leakage

Severe reflux of gastric acid causing heartburn

There is a technical failure of the primary procedure such as dilation of the gastric pouch or gastrojejunostomy anastomosis as noted by diagnostic imaging (e.g. GI series), as well as:

the individual experienced weight loss prior to the technical failure

the individual was compliant with the prescribed postoperative diet and exercise programs

Conversion to an alternative procedure if the member has inadequate weight loss which is defined as failure to lose at least 50% of excess body weight or failure to achieve body weight to within 30% of ideal body weight at least two years following the original surgery and they have been compliant with prescribed nutrition and exercise program. Body weight and BMI information is available from the National Heart Lung and Blood Institute [NHLBI) BMI tables

If Your Policy Does NOT Cover It: Seek Partial Coverage

You may be able to get part of the costs paid for by insurance even if weight loss surgery isn’t covered. It’s all about how your doctor and hospital submit your claims to your insurance company.

For example, there are many non-bariatric surgery reasons for your doctor to recommend:

Cardiology exam

Lab work

Medically supervised diet program

Psychological exam

Sleep study

These are ordered for many reasons other than bariatric surgery and may be covered as a result. If your doctor submits one of these claims using a weight loss surgery CPT code (Current Procedural Terminology Code), your insurance is unlikely to cover it. But if your doctor uses a general CPT code, it probably will be covered.

While this may sound “sneaky”, it is an ethical practice. After all, these tests will be beneficial regardless of whether you move forward with surgery.

Coverage by Plan Type

SECTION SUMMARY:

Coverage Through Your Employer

Individual & Family Plans

Medicare

Before getting into the types of insurance plans, you can cut to the chase by contacting a local bariatric surgeon’s office. Most surgeons will contact your insurance company for free to confirm whether or not you’re covered.

Contact your insurance company directly using the phone number on your insurance ID card

Weight Loss Surgery for Individual/Family Plans

The Affordable Care Act (Obamacare) requires all individual and small group plans (less than 50 full time employees) to include weight loss surgery coverage as long as it is considered an “Essential Health Benefit” in your state.

The following states DO currently consider bariatric surgery an Essential Health Benefit (bariatric surgery is covered by all individual, family and small group plans in these states):

Your State Not on the List?

If your state is NOT on the list, then weight loss surgery is probably NOT covered under your plan.

Open Vs. Laparoscopic Surgery

Most patients who are candidates for open bariatric surgery are also candidates for laparoscopic bariatric surgery. The only significant contraindications to laparoscopic surgery necessitating an open procedure include BMI greater than 70 and hepatomegaly, due largely to the poor exposure and instrumentation afforded in these cases.

Procedures That Are NOT Covered

Health Net, Inc. considers any of the following procedures investigational because the medical literature indicates that studies have been inadequate to determine their efficacy and long-term outcomes:

Bariatric Procedure Cost Compare Tool

Your out-of-pocket bariatric surgery cost can range anywhere from $0 to $20,000 or more depending on several factors, including:

Whether your insurance covers it – many insurances (including Medicare, Medicaid, and many individual/family and employer-provided policies) cover the majority of costs for gastric sleeve, gastric bypass, LAP-BAND®, and duodenal switch. The other types of bariatric surgery are less likely to be covered, although you may be able to get insurance to pay for some of the costs. Tap the “With Insurance” button in the tool to see average out-of-pocket costs per procedure after insurance pays. See our Insurance Tool to find out if your plan covers it.

Which procedure you choose – if insurance won’t pay, costs range anywhere from $8,000 to $20,000+, depending on the procedure. Tap the “Without Insurance” button in the tool to compare the national average self-pay costs for each procedure. (NOTE: Some surgeons offer each procedure for as low as half of the national average).

How competitive your surgeon and hospital fees are – there is often a substantial difference in costs between different doctors and hospitals, even within the same town.

Whether you qualify for tax write-offs – Bariatric surgery is tax deductible, which can have a big impact on the total cost of surgery. You can deduct medical expenses if your out-of-pocket costs are more than 10% of your adjusted gross income. See our Tax Tool to find out if your bariatric procedure will be tax deductible.

How you choose to pay for your procedure – If insurance covers it, you’ll only be responsible for any copays, deductibles, and coinsurance required by your specific plan. If you pay for the procedure without insurance, total costs will depend on how you pay. For example, your surgeon may offer a discount if you pay the full amount up front, and you can make the costs more affordable by applying for bariatric surgery financing.

LOAN ESTIMATOR TOOL

Weight loss surgery is tax deductible, which can have a big impact on the total cost of surgery. You can deduct medical expenses if the costs are more than 10% of your adjusted gross income.

Use the tool to find out if you qualify for a tax deduction.

To receive the deductions, you’ll need to complete Schedule A of the IRS Form 1040. You’ll also need to save your medical bills and payment statements as proof. Money in one of the following special savings accounts (or even your IRA) may also be a way to pay for part of surgery tax-free:

*Disclaimers:Content: The information contained in this website is provided for general information purposes and your specific results may vary depending on a variety of circumstances. It is not intended as nor should be relied upon as medical advice. Rather, it is designed to support, not replace, the relationship that exists between a patient/site visitor and his/her existing physician(s). Before you use any of the information provided in the site, you should seek the advice of a qualified medical, dietary, fitness or other appropriate professional. Advertising: Bariatric Surgery Source, LLC has entered into referral and advertising arrangements with certain medical practices, original equipment manufacturers, and financial companies under which we receive compensation (in the form of flat fees per qualifying action) when you click on links to our partners and/or submit information. This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply. Read More